Bipolar Disorder in Children and Adolescents

Background

• Bipolar disorder is a mood disorder characterized by recurrent episodes of elevated or irritable mood, and depression, which are separated by periods of more moderate mood.
• Bipolar disorder is reported to affect 1%-2% of youths aged 7-21 years. Bipolar disorder is more commonly diagnosed after puberty.
  • Diagnosis of bipolar disorder before puberty has been historically controversial, though bipolar symptoms have been reported in preschool- and early elementary school-age children.
  • Due to concerns of over- or inappropriate diagnosis in very young children, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) stresses that mania and hypomania (which may present as irritability) must be episodic and clearly a change from baseline in order to meet criteria for a diagnosis of bipolar disorder in all pediatric patients.
• A family history of psychiatric disorder, particularly bipolar disorder, increases the risk of bipolar disorder in children and adolescents.
• Children and adolescents with bipolar disorder may have psychiatric comorbidities, such as an anxiety disorder, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder, or a substance use disorder.
• The clinical course of bipolar disorder in children and adolescents is associated with high rates of recovery, but also high rates of relapse.

Evaluation

• Suspect bipolar disorder in youths with history of periodic extreme changes in mood or behavior uncharacteristic of the individual, which are developmentally inappropriate, and have clear an impact on functioning.
• Compared to presentations of bipolar disorder in adults, children with bipolar disorder may be more likely to present with irritability as a manic manifestation, and/or with shorter episodes of mood disturbance, mixed episodes, or rapid-cycling of symptoms.
• Distinguish symptoms, particularly irritability and depression, from other psychiatric disorders, including disruptive mood dysregulation disorder (DMDD), ADHD, oppositional defiant disorder, depression, posttraumatic stress disorder (PTSD), substance use, and anxiety disorders.
• The DSM-5 provides diagnostic criteria for bipolar disorder.
  • Bipolar I disorder is characterized by at least 1 episode of mania, and usually episodes of depression and/or hypomania.
  • Bipolar II disorder is characterized by a history of major depressive episodes and hypomanic episodes only, without episodes of mania.
  • Mania is defined as at least 1 week of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy along with at least 3-4 other manic symptoms such as grandiosity, decreased need for sleep, or pressured speech which result in social impairment, hospitalization, or psychosis.
  • Hypomania has the same elements as mania except that symptoms need only be present for 4 days and while they represent a noticeable change from usual behavior they do not cause social impairment, hospitalization, or psychosis.
  • A major depressive episode is defined as having at least 5 depressive symptoms within the same 2-week period such as depressed mood, loss of interest in activities, feelings of worthlessness, suicidal ideation, decreased appetite, energy, or concentration, psychomotor changes, and hypersomnia or insomnia which cause clinically significant distress or impairment in functioning (see also Major depressive disorder (MDD)).
  • Bipolar disorder not otherwise specified (NOS) is characterized by not meeting criteria for major depression, bipolar I disorder, bipolar II disorder, or cyclothymia, such as < 1 week of manic symptoms without psychosis or hospitalization.
  • Bipolar disorder with "mixed features" requires ≥ 3 symptoms from opposite pole during depressive, hypomanic, or manic episodes.

Management

• The primary management of pediatric bipolar disorder is a combination of medication and psychosocial counseling.
• For acute mania or mixed mania
  • Consider a second-generation antipsychotic, such as aripiprazole, asenapine, olanzapine, or risperidone.
  • Consider lithium for bipolar mania for patients who don't respond to, or have contraindications to, second-generation antipsychotics. There is limited evidence of efficacy for other mood stabilizers in pediatric bipolar disorder.
  • FDA-approved medications for acute manic or mixed episode in patients ≥ 10 years old are aripiprazole, asenapine, olanzapine, quetiapine, and risperidone; lithium is approved for acute mania in bipolar disorder in children ≥ 12 years old.
• For bipolar depression
  • Consider a second-generation antipsychotic. Mood switching is a potential risk with antidepressant monotherapy in bipolar patients. There is limited evidence of efficacy for lithium or lamotrigine.
  • FDA-approved medications for acute bipolar depression in patients aged ≥ 10 years old include olanzapine plus fluoxetine, and lurasidone; lithium is FDA-approved for bipolar disorder in patients ≥ 12 years old.
• For maintenance treatment in bipolar disorder, review the effectiveness of treatment for acute symptoms and consider long-term management with structured individual or family counseling.
• Consider psychotherapy for children with pediatric bipolar disorder, including family psychoeducation plus skill building, dialectical behavior therapy, or cognitive behavioral therapy.
• Provide regular follow-up evaluations including assessment for the presence of suicidal thoughts or behaviors as well as monitoring of medications.